India’s Central Bureau of Investigation (CBI) is investigating a series of scams totalling Rs 10,000 crore in Uttar Pradesh around the use of funds meant for the National Rural Health Mission (NRHM) launched in 2005. SPR Foundation’sSourjya Bhowmick looks at the implementation of the programme in the state over the last 5 years and finds that citizens in the past were not just denied medical facilities but illegally forced to pay and scrounge for even the little that was in existence.

The NRHM was initiated as an effort to provide better healthcare to rural India with a special focus on 18 states. Uttar Pradesh falls under the category of ‘high focus states’. We take a look at UP before and after the introduction of NRHM. Here are some illustrations from a Planning Commission study in 2007.

a) Manju of Lucknow (Jan, 2007) was asked for Rs 10,000 by the doctor at a Maternal Health Centre before her case could be admitted.

b) Durmati of Kushinagar (Aug, 2006) was asked for Rs 1000 by the ANM at the PHC for doing her delivery.

c) Salenta at Muzzafarnagar (Feb, 2007) spent Rs 50,000 trying to repair a Vesicovaginal Fistula caused during her childbirth at the local PHC. Her husband works at a brick kiln.

d) Asha of Azamgarh ( Sept, 2006) died because the ANM consulted failed to recognize her life threatening ante natal complication and did not refer her on time.

e) Babita of Chandauli (March, 2007) was asked for Rs 500 as a share of the JSY (Janani Suraksha Yojana) money by the ANM at PHC.

Before NRHM

Now let’s take a look at the state of healthcare in UP before NRHM was introduced. By way of background, Uttar Pradesh (Census 2011) is the most populated state in the country at 199 million residents, which is nearly 16 percent of India’s 1.2 billion strong population.

1. Infant Mortality Rate was 76 while for the country, it was 60 in 2003.

3. 90% of deliveries occurred at home in 2001-2003. Around 70.8 % of the births in UP (76.2% in rural areas) appear to have been handled by non-health personnel.

4. Children aged 12-24 months receiving complete vaccination was 23%.

5. Percent of women receiving 3 or more antenatal visits was 26.6.

6. Births assisted by ANM’s/doctors/health personnel were 29.2%.

Uttar Pradesh had 388 Community Health Centres, 823 Block Primary Health Centres, and 2,817 Sub Block PHCs apart from 20,521 Sub Centres. As an insight, in 2000-2005, a World Bank health systems programme found that less than 20% Community Health Centres (CHCs) surveyed in Uttar Pradesh had the minimum (60%) basic equipment needed to handle an obstetric emergency, and barely a third had 60% of the qualified medical staff required.

NRHM’s Infrastructural Flaws

Now let us take a closer look at the progress of NRHM. Uttar Pradesh had 515 CHCs, 3690 PHCs, and 20521 Sub Centre’s before NRHM. Since inception of NRHM only 582 CHCs, 700 PHCs, and 5823 SCs have been added to rural health services of UP.

Of all the PHC’s functioning in the state, less than 50% (45.5%) was functioning on a 24*7 basis in 2007-2008. Around 10% functioned without Auxiliary Nurse Mid Wives (ANMs). Interestingly, only Delhi and Kerala were in a worse condition than UP with 43% and 11.7%.

About 4,633 infrastructure projects, which included creation or up-gradation of CHCs, PHCs were undertaken by the Uttar Pradesh Government. However, only 350 of these projects were actually completed.

Inadequate MMUs & Ambulances

Mobile Medical Units (MMU) is an integral part of rural healthcare. However, UP had zero MMU’s, as per a 2010 document. Obviously, it was the worst performer. Other smaller high focus states like Jharkhand, Orissa had 90 and 171 MMUs respectively. Himachal Pradesh, another high focus state has no MMUs. Interestingly, Kerala and West Bengal, who are better off than the high focus states didn’t have any MMUs.

Uttar Pradesh again had no provision of ambulances in its CHC’S and PHC’s. Other high focus states like Jharkhand and Assam had 359 and 650 ambulances respectively. And yet, according to the Comptroller & Auditor General (CAG), 779 ambulances were purchased at a cost of Rs 55 crore of which 620 were still parked outside the Tata Motors yard.

UP’s Manpower Shortcomings

ASHA, a female community health activist, selected from the village itself plays an important part in the scheme of NRHM. A total of 1, 35,522 women had been selected. But training was provided to only 1, 27,145 of the workers and drug kits were given to about 1, 24,309 of the trained community workers. The state seems to be in a far better position than the other high focus states. In Himachal Pradesh for instance 2393 were selected but none were given training.

While the number of community workers might be more than those of Himachal Pradesh, there is quite a deficiency when it comes to manpower in Health centres in Uttar Pradesh. The vacancies in positions of doctors and other health workers in CHCs and PHCs can be noted below.

Particulars

Required

In Position

Shortfall

Doctors at PHC’s

3690

2001

1689

Nurse/Mid wives

7295

3340

3955

Specialists in CHC’s

2060

618

1442

Another study by the Planning Commission (based on Andhra, UP, Rajasthan and Bihar) clearly points out the manpower situation in UP. The NRHM states that there should be 9 staff nurses per CHC, 3 staff nurses per PHC and 2 ANMs per Sub Centre. Uttar Pradesh doesn’t have the required number of staff nurses and is in fact the second worst performer among all the high focus states.

However, in terms of numbers of paramedics employed at CHC level Uttar Pradesh’s performance is just better than Bihar with an average of 5.8 per centre. Andhra Pradesh and Rajasthan have an average of 11 and 8. At PHC level, Rajasthan has the lead with 5 paramedical persons employed at each centre. UP’s average was 3.6 per centre, better than states like Andhra Pradesh and Bihar. At the Sub centre level the target is to have 2 ANMs but all these four states have only 1.

Poorly Qualified Medical Officers

When it comes to having qualified Medical officers with an MBBS degree in a CHC and PHC, Uttar Pradesh has the worst figures, with an average of 2.9 (1.3 in CHCs and 1.6 in PHCs). Andhra Pradesh and Rajasthan have an average of more than 4 MBBS holding Medical Officers. There are no Anaesthetists at the PHC level and at the CHC level, there are less than 1 (0.6).

The population of obstetricians/gynaecologists, at the PHC level is almost non-existent and at the CHC level the average is 0.8. UP also has a dismal attendance record for its paramedical staffs in the CHCs and the PHCs with 48% and 39% respectively. Medical Officer Attendance record at the CHC level is 36%.

When it comes to medicines, only 33% and 29% of all the CHCs and the PHCs had an adequate storage of drugs.

Japanese Encephalitis has caused routine deaths to increase to more than 500. The NRHM document says that the inability to detect the disease early is a major cause for the increase in the number of deaths. Surveillance workers would be required to monitor patients for symptoms, but this doesn’t happen as there are a lot of vacant posts. In 2009, a total of 40 disease outbreaks were reported.

Infant Mortality Rate in 2005 was 73 and in 2008 it was 67, while the national average was 53. Maternal Mortality Ration has been 440, the national average is 254. According to the Health Ministry, there are no rural dispensaries, City Family Welfare Centres or Referral Hospitals in the state.

When it comes to methods of family planning, Uttar Pradesh ranks 24th in the country based on theNational Family Health Survey. Based on the usage of IUCDs (Intra Uterine Contraceptive devices), UP is ranked 19 among the states in the country. Till 2011, the sterilisation achievement percentage in UP was 39 percent. Only 39% of the people use oral pills.

Poor Maternal Health In UP

The condition of maternal health in Uttar Pradesh is very poor.

a) Only 26% pregnant women in the state received total Antenatal Care. About 75% of the women were from urban areas while 43% of the women were from rural areas in the state.

b) 52% of pregnant women, between 15 to 49 years age, were anaemic.

c) 29% of births were assisted by a doctor/ANM’s (Auxiliary Nurse Mid Wives). National average is 49%.

Uttar Pradesh ranks 27th out of all the states in Maternal Health Care.

Let us see UP’s ranking among other states as on Feb, 2010 based on a few important indicators:

Indicators

Rank among all states

%

Usage of Pill

21

1.7

Use of IUD

19

1.4

Mothers who had at least 3antenatal care visits for their

last birth (%)

28

26.3

Births assisted by a doctor/nurse/LHV/ANM/otherhealth personnel (%)

27

29.20

Mothers who received postnatal care from a doctor/nurse/LHV/ANM/other health personnelwithin 2 days of delivery for their last birth (%)